Vendor Application/renewal - State Of California - Health And Human Services Agency
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1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
VENDOR APPLICATION/RENEWAL
ADMINISTRATOR CERTIFICATION PROGRAM
Instructions: To apply to become (or to renew as) a course vendor for this Program, submit this completed application and a check or money order for
the applicable processing fee to CDSS, ACS, 744 “P” Street, MS 9-14-47, Sacramento, CA 95814. Submit a separate vendor application and check or
money order for each type of program (ARF, GH, RCFE) and vendorship (ICTP or CEU).
(1) Type of Application: (Check one box only. If renewing, provide vendor number and expiration date, and attach LIC 9139 if renewing courses.)
I
I
I
I
New
Renewal Vendor #_____________________________ Expires: ___________________ LIC 9139 attached?
YES
NO
(2) Type of Program: (Check one box only; if applying for more than one, submit separate application for each.)
I
I
I
ARF (Adult Residential Facility)
GH (Group Home)
RCFE (Residential Care Facility for the Elderly)
(3) Type of Vendor: (Check one box only; if applying for both types, submit separate applications.)
I
I
ICTP (Initial Certification Training Program) Vendor ($150 Fee)
CEU (Continuing Education) Vendor ($100 Fee)
(4) Applicant Information: (Please print.)
Organization/Vendor Business Name:______________________________________________________________________________________
Address (Street Address, City, State, Zip): __________________________________________________________________________________
Authorized Representative/Contact Person (Name): ___________________________________________________________________________
Business Phone Number: _________________________ Fax: ________________________ E-mail:___________________________________
Company Website:_________________________________
Company Type: (Check one box. Provide documentation of authority to conduct business in California (e.g., certificate of status from CA
Secretary of State).
I
I
I
Individual
University, College or School
Provider Association
I
I
I
Partnership
Non-Profit Organization
Corporation
I
I
Government Agency
Other:_____________________________________
List each individual authorized representative/contact person (e.g., partner, Executive Director, and/or board members) and their titles. Each
Name
Title/Position
Sec’s 6-10 Completed ?
person listed in this section must complete and sign Sections 6-10 on page 2 of this form. (Copy page 2 as needed).
Signature of Vendor/Authorized Representative
Printed Name of Vendor/Authorized Representative
Title
Date
DO NOT WRITE BELOW THIS LINE
I
I
Application/Renewal has been
approved OR
disapproved by:
Date:
Approved Vendor Number
Expiration Date:
LIC 9141 (1/16)
PAGE 1 OF 2
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